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City of Columbus Employee Benefit Plan Restate Effective January 1, 2017

Plan Document and

Summary Plan Description for the

City of Columbus Employee Benefit Plan

Medical Benefits

Prescription Drug Benefits

City of Columbus Employee Benefit Plan Restate Effective January 1, 2017 i

INTRODUCTION

City of Columbus (the “Employer” or “Plan Sponsor”) is pleased to offer you this benefit plan. It

is a valuable and important part of your overall compensation package.

This booklet describes your medical and prescription drug benefits and serves as the Summary

Plan Description (SPD) and Plan document for the City of Columbus Employee Benefit Plan

(“the Plan”). It sets forth the provisions of the Plan that provide for payment or reimbursement of

Plan benefits.

Because the sponsor of the Plan is a governmental agency, the Plan is not subject to the Employee Retirement Income Security Act of 1974 (ERISA).

We encourage you to read this booklet and become familiar with your benefits. You may also

wish to share this information with your enrolled family members.

This SPD and Plan replace all previous booklets you may have in your files. Be sure to keep

this booklet in a safe and convenient place for future reference.

Patient Protection and Affordable Care Act. The City of Columbus Employee Benefit Plan

believes this plan is not a “grandfathered health plan” under the Patient Protection and

Affordable Care Act (the Affordable Care Act). For more information, contact the Employee

Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or

www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and

do not apply to grandfathered health plans.

http://www.dol.gov/ebsa/healthreform

TABLE OF CONTENTS

INTRODUCTION .................................................................................................................................. i SECTION I: DEFINITIONS .................................................................................................................. 1 SECTION II: PLAN OVERVIEW ......................................................................................................... 11

Your Eligibility ............................................................................................................................ 11 Eligible Dependents ................................................................................................................... 11 Working Spouse Rule ................................................................................................................ 12 Proof of Dependent Eligibility ..................................................................................................... 13 Eligible Retirees ........................................................................................................................ 13 When Coverage Begins ............................................................................................................. 14

Look-back Measurement Method for Determining Full-time Employee Status .................. 14 For You ............................................................................................................................ 15 For Your Dependents ....................................................................................................... 15

Your Cost for Coverage ............................................................................................................. 16 Enrolling for Coverage ............................................................................................................... 16

New Hire Enrollment ........................................................................................................ 16 Late Entrant ..................................................................................................................... 17

Open Enrollment ....................................................................................................................... 17 Effect of Section 125 Tax Regulations on this Plan .................................................................... 17 Qualifying Change in Status ...................................................................................................... 18 Special Enrollment Rights.......................................................................................................... 19 When Coverage Ends ............................................................................................................... 19 Reinstatement of Coverage ....................................................................................................... 20 Cancellation of Coverage .......................................................................................................... 21 Rescission of Coverage ............................................................................................................. 21 Coverage While Not at Work ..................................................................................................... 21 If You Are Disabled or FMLA Approved Leave ........................................................................... 21 If You Are Temporarily Laid Off .................................................................................................. 21 Leave of Absence ...................................................................................................................... 21 Continuation during Family and Medical Leave ......................................................................... 22 If You Take a Military Leave of Absence ..................................................................................... 22 If You Are Permanently Laid Off ................................................................................................. 22

SECTION III: YOUR MEDICAL BENEFITS ....................................................................................... 23 Your Deductible ......................................................................................................................... 25

PPO Deductible Accumulation: Embedded ...................................................................... 25 HDHP Deductible Accumulation: Non-Embedded ............................................................ 25 High Deducible Health Plan with Health Savings Account ................................................ 25

Your Copayment ........................................................................................................................ 25 PPO Plan Special Copayment for Non-Emergency Use of Emergency Room ................. 26

Coinsurance Stop Loss Amount................................................................................................. 26 Out-of-Pocket Limit .................................................................................................................... 26 Summary of Medical Benefits .................................................................................................... 27

PPO Plan ......................................................................................................................... 27 HDHP Plan ...................................................................................................................... 31

Eligible Expenses ...................................................................................................................... 35 Expenses Not Covered .............................................................................................................. 47 Pre-certification ......................................................................................................................... 52

Procedure ........................................................................................................................ 52 Penalty for Noncompliance with Precertification ............................................................... 53 Utilization Review ............................................................................................................. 53

Case Management .................................................................................................................... 53 SECTION IV: YOUR PRESCRIPTION DRUG BENEFITS ................................................................. 55

How the Plan Works .................................................................................................................. 55 Managed Pharmacy Network .................................................................................................... 55 Using a Network Retail Pharmacy ............................................................................................. 55 If You Use an Out-of-Network Retail Pharmacy ......................................................................... 55 Direct Member Reimbursement ................................................................................................. 55 Coverage Categories ................................................................................................................. 55 Prescription Formulary Drug Tiers ............................................................................................. 56 Prescription Copayments – PPO Plan ....................................................................................... 56 Prescription Deductible/Coinsurance – HDHP Plan ................................................................... 56 Prior Authorization and Limits .................................................................................................... 57 Specialty Medications ................................................................................................................ 57 Covered Prescription Drugs and Supplies ................................................................................. 57 Expenses Not Covered .............................................................................................................. 59 Summary of Pharmacy Benefits ................................................................................................ 61

SECTION V: ADMINISTRATIVE INFORMATION .............................................................................. 63 Plan Sponsor and Administrator ................................................................................................ 63 Plan Year ................................................................................................................................... 64 Type of Plan .............................................................................................................................. 64 Plan Number ............................................................................................................................. 64 Identification Numbers ............................................................................................................... 64 Plan Funding and Type of Administration ................................................................................... 64 Claims Administrators ................................................................................................................ 64 Agent for Service of Legal Process ............................................................................................ 65 Future of the Plan ...................................................................................................................... 65

SECTION VI: PLAN ADMINISTRATION ............................................................................................ 66 Plan Administrator ..................................................................................................................... 66 Duties of Plan Administrator ...................................................................................................... 66 Plan Administrator Compensation .............................................................................................. 66 Indemnity ................................................................................................................................... 66 Fiduciary .................................................................................................................................... 67 Fiduciary Duties ......................................................................................................................... 67 Named Fiduciary ....................................................................................................................... 67 Claims Administrator is Not Fiduciary ........................................................................................ 67 Clerical Error ............................................................................................................................. 67 Amending and Terminating Plan ................................................................................................ 68

SECTION VII: PROCEDURES FOR OBTAINING OR DETERMINING BENEFITS ........................... 69 Claim Filing ............................................................................................................................... 69

Non-Participating Providers ............................................................................................. 69 Claim Form ...................................................................................................................... 69

Claim Determination .................................................................................................................. 69 Pre-Service Claims .......................................................................................................... 69 Post-Service Claims ......................................................................................................... 70 Urgent Care Claims ......................................................................................................... 70 Concurrent Care Claims ................................................................................................... 71

Grievances ................................................................................................................................ 71 Appeal Procedures .................................................................................................................... 72

General ............................................................................................................................ 72 Claimant’s Rights on Appeal ............................................................................................ 73 Appeals Hearing Committee ............................................................................................ 73

Notification of Resolution of Appeal .................................................................................. 73 Expedited Appeals ........................................................................................................... 74 Initial Notice of Decision on Appeal .................................................................................. 74 Subsequent Appeal Participants ...................................................................................... 74 Subsequent Appeal Process ............................................................................................ 75 Subsequent Notices of Decision on Appeal ...................................................................... 76 External Review of Appeals Process ................................................................................ 76 Notification of Decision..................................................................................................... 78

Coordination of Benefits ............................................................................................................ 78 Standard Coordination of Benefits ................................................................................... 78 How Standard Coordination Works .................................................................................. 78 Determining Primary and Secondary Plans ...................................................................... 78 Coordination with Medicare .............................................................................................. 80 Coordination with Auto Insurance Plans ........................................................................... 80 For Maximum Benefit ....................................................................................................... 80

Subrogation and Reimbursement .............................................................................................. 80 Right of Recovery ............................................................................................................ 81 Right to Subrogation ........................................................................................................ 81 Right to Reimbursement .................................................................................................. 81 Third Parties .................................................................................................................... 81 Pay and Pursue ............................................................................................................... 82 When This Provision Applies To You ................................................................................ 82

SECTION VIII: YOUR HIPAA/COBRA RIGHTS ................................................................................ 84 Health Insurance Portability and Accountability Act of 1996 (HIPAA) ......................................... 84 Protected Health Information and its Disclosure ........................................................................ 84 Certificate of Creditable Coverage ............................................................................................. 85 Continuing Health Care Coverage through COBRA ................................................................... 86 COBRA Qualifying Events and Length of Coverage .................................................................. 86

18-Month Continuation ..................................................................................................... 86 18-Month Continuation Plus 11-Month Extension ............................................................. 87 36-Month Continuation ..................................................................................................... 87

COBRA Notifications ................................................................................................................. 88 Cost of COBRA Coverage ......................................................................................................... 88 COBRA Continuation Coverage Payments ................................................................................ 88 How Benefit Extensions Impact COBRA .................................................................................... 89 When COBRA Coverage Ends .................................................................................................. 89

SECTION IX: GENERAL PROVISIONS ............................................................................................ 90 No Obligation to Continue Employment ..................................................................................... 90 Payment of Benefits .................................................................................................................. 90 Payment of Benefits to Others ................................................................................................... 90 Non-Alienation of Benefits ......................................................................................................... 90 Expenses .................................................................................................................................. 90 Fraud ......................................................................................................................................... 90 Typographical or Administrative Error ........................................................................................ 90 Severability ................................................................................................................................ 91 Incontestability ........................................................................................................................... 91 Limitation of Action .................................................................................................................... 91 Governing Law .......................................................................................................................... 91 Conformity with Statutes and Regulations ................................................................................. 91 Non-discrimination ..................................................................................................................... 91 Discrimination is Against the Law .............................................................................................. 91

ADOPTION OF THE PLAN ............................................................................................................... 94

City of Columbus Employee Benefit Plan Restate Effective January 1, 2017 Page 1

SECTION I: DEFINITIONS

Accident: an unexpected or reasonably unforeseen occurrence or event that is definite as to

time and place.

Active Employee (Actively at Work): a Participant is considered “actively at work” if he or she:

is presently at work on a scheduled workday performing the regular duties of his or her

job for the hours he or she is normally scheduled to work; or

was present at work on the last scheduled working day before:

o a scheduled vacation;

o an absence due to a paid holiday, paid jury or witness day, or a paid

bereavement day;

o a scheduled day off within the participant’s working schedule; or

o an absence excused by the Plan Sponsor.

Acute Rehabilitation: designed to provide intensive rehab therapy in a resource intensive

inpatient hospital environment for patients who, due to the complexity of their nursing, medical

management and rehabilitation needs require and can be reasonably expected to benefit from

an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitative care.

Criteria are 24 hours of nursing and medical oversight and multidisciplinary rehab therapy

providers.

Ambulatory Surgical Center: a licensed facility that is used mainly for performing outpatient

surgery, has a staff of Physicians, has continuous Physician and nursing care by registered

nurses (R.N.s) and does not provide for overnight stays.

Appeal: a resort to a higher authority or greater power, as for sanction or a decision.

Birthing Center: means any freestanding health facility, place, professional office or institution

which is not a Hospital or in a Hospital, where births occur in a home-like atmosphere. This

facility must be licensed and operated in accordance with the laws pertaining to Birthing Centers

in the jurisdiction where the facility is located.

The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after

delivery; provide care under the full-time supervision of a Physician and either a registered

nurse (R.N.) or a licensed nurse-midwife; and have a written agreement with a Hospital in the

same locality for immediate acceptance of patients who develop complications or require pre- or

post-delivery confinement.

Brand Name: means a trade name medication.

Calendar Year: January 1st through December 31st of the same year.

Certified Nurse-Midwife: A registered nurse (R.N.) certified by the American College of Nurse-

Midwives.

City of Columbus Employee Benefit Plan Restate Effective January 1, 2017 2

Chiropractic Care: services provided by a Chiropractor (D.C.) or licensed physician (M.D. or

D.O.) including office visits, diagnostic x-rays, manipulations, supplies, heat treatment, cold

treatment and massages.

Claims Administrator: refers to the individual business or entity, if any, appointed and retained

by the Plan Administrator to supervise the administration, consideration, investigation, and

settlement of claims, maintain records, and offer such ministerial and supportive functions as

may be set forth in a written administrative agreement. If no Claims Administrator is appointed

or retained (as a result of the termination or expiration of the administrative agreement or any

other reason) or if the term is used in connection with a duty not expressly assigned to and

assumed by an entity in writing, the term will mean the Plan Administrator. Both the ultimate

responsibility for the administration of this Plan and the final authority to interpret the Plan

should remain with the Plan Administrator.

Coinsurance: the percentage of the cost of covered expenses a Participant must pay after

meeting any applicable deductible.

Complete Claim: a previously incomplete claim for which a Participant has submitted the

missing or additional information required for the Plan to make a determination.

Concurrent Care Claim: a claim for a benefit that involves an ongoing course of treatment.

Confinement: an inpatient admission to a healthcare facility.

The Consolidated Omnibus Budget Reconciliation Act (“COBRA”): this Federal law, as

amended, allows a continuation of health care coverage in certain circumstances.

Copayment

The fixed dollar amount of covered expenses a participant must pay before Plan pays.

Cosmetic Dentistry: dentally unnecessary procedures.

Covered Expense: an expense that will be reimbursed according to the terms of the Plan.

Covered Family is the covered Employee or Retiree or Dependent who is covered under the

Plan.

Custodial Care: services and/or care not intended primarily to treat a specific injury or illness

(including mental health and substance abuse) which services/care include, but are not limited to:

services related to watching or protecting a person;

services related to performing or assisting a person in performing any activities of daily

living, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting,

eating, preparing foods, or taking medications that usually can be self-administered; and

services not required to be performed by trained or skilled medical or paramedical

personnel.


Deductible: the dollar amount (for individual or family) a Participant is responsible to pay each

year before the Plan begins to pay benefits.

Diagnostic: a test or procedure performed for specified symptoms to detect or to monitor a

disease or illness and ordered by a physician or professional provider.

Doctor or Physician: a doctor of medicine (M.D.) or doctor of osteopathy (D.O.). The term also

includes a chiropractor (D.C.), dentist (D.M.D. or D.D.S.), or a podiatrist (D.P.M.). In all cases,

the person must be legally qualified and licensed to perform a service at the time and place of

the service.

Durable Medical Equipment (“DME”): equipment which

- can withstand repeated use;

- is primarily and customarily used to serve a medical purpose;

- generally is not useful to a person in the absence of an illness or injury; and

- is appropriate for use in the home.

Eligible Provider: any practitioner or facility offering covered services and acting within the

scope of the appropriate license; examples include a licensed doctor, specialist, osteopath,

podiatrist, chiropractor, hospital, or laboratory.

Emergency Services: a medical screening examination (as required under §1867 of the Social

Security Act (EMTALA) within the capability of the Hospital Emergency Department, including

routine ancillary services, to evaluate a Medical Emergency and such further medical

examination and treatment as are within the capabilities of the staff and facilities of the Hospital

and required under EMTALA to stabilize the patient.

Medical Emergency is defined means a medical condition manifesting itself by acute symptoms

of sufficient severity including severe pain such that a prudent layperson with average

knowledge of health and medicine could reasonably expect the absence of immediate medical

attention to result in (1) serious jeopardy to the health of an individual (or, in the case of a

pregnant individual, the health of the individual unborn child), (2) serious impairment to body

functions, or (3) serious dysfunction of any body organ or part.

Employee: a person who works for the Plan Sponsor in an employer-employee relationship.

Emergency Dental Care: An urgent, unplanned diagnostic visit and/or alleviation of acute or

unexpected Dental condition.

Employer: City of Columbus

Enrollment Date: the first day of coverage or, if there is a Waiting Period, the first day of the

Waiting Period.


Experimental or Investigational Services: Medical, surgical, diagnostic, psychiatric,

substance abuse, or other health care services, technologies, supplies, treatments, procedures,

drug therapies, or devices that, at the time the Plan makes a determination regarding coverage

in a particular case, are determined to be:

not approved by the FDA to be lawfully marketed for the proposed use and not identified in

the American Hospital Formulary Service or the United States Pharmacopoeia Dispensing

Information as appropriate for the proposed use;

subject to review and approval by any institutional review board for the proposed use;

the subject of an ongoing clinical trial that meets the definition of a phase 1, 2, or 3

clinical trial set forth in the FDA regulations, regardless of whether the trial actually is

subject to FDA oversight; or

not demonstrated through authoritative medical or scientific literature published in the

U.S. to be safe and effective for treating or diagnosing the condition or illness for which

its use is proposed.

Family and Medical Leave Act (“FMLA”): a Federal law, as amended, that provides for an

unpaid leave of absence of up to 12 weeks per year for:

the birth or adoption of a child or placement of a foster child in a participant’s home;

the care of a child, spouse or parent (not including parents-in-law), as defined by Federal

law, who has a serious health condition;

a participant’s own serious health condition; or

any qualifying exigency arising from an employee’s spouse, son, daughter, or parent

being a member of the military on “covered active duty”. Additional military caregiver

leave is available to care for a covered service member with a serious injury or illness

who is the spouse, son, daughter, parent, or next of kin to the employee.

Generally, you are eligible for coverage under FMLA if you have worked for your Plan Sponsor

for at least one year; you have worked at least 1,250 hours during the previous 12 months; your

Plan Sponsor has at least 50 employees within 75 miles of your worksite; and you continue to

pay any required premium during your leave as determined by the Plan Sponsor. You should

contact the Plan Sponsor with any questions you have regarding eligibility for FMLA coverage or

how it applies to you.

FDA: the United States Food and Drug Administration.

Formulary: a list of prescription drugs that represent safe, effective therapeutic medications

covered by the Plan including:

Generic;

Preferred Brand Name; and

Non-Preferred Brand Name

Foster Child: means a child for whom a covered Employee has assumed a legal obligation in

connection with the child's placement with a state, county or private foster care agency. A


covered Foster Child is not a child temporarily living in the covered Employee's home; one

placed in the covered Employee's home by a social service agency which retains control of the

child; or whose natural parent(s) may exercise or share parental responsibility and control.

Generic Drug Alternative: a generic drug that is not the exact equivalent of the brand-name

drug, but can be used to treat that medical condition. For example, there are generic options to

treat high cholesterol.

Generic Drug Equivalent: a generic drug that has the exact same active ingredients as the

brand-name drug. When a drug patent expires, other companies may produce a generic version

of the brand-name drug. A generic medication (also approved by the FDA) is basically a copy of

the brand-name drug and is marketed under its chemical name. A generic may have a different

color or shape than the brand name, but it must have the same active ingredients, strength, and

dosage form (i.e., pill, liquid, or injection), and provide the same effectiveness and safety.

GINA: The Genetic Information Nondiscrimination Act of 2008, as amended.

HIPAA: Health Insurance Portability and Accountability Act of 1996, as amended.

HITECH: The Health Information Technology for Economic and Clinical Health Act, as amended.

Home Health Care Agency: is an organization that meets all of these tests: its main function is

to provide Home Health Care Services and Supplies; it is federally certified as a Home Health

Care Agency; and it is licensed by the state in which it is located, if licensing is required.

Hospice: a licensed (if required by the state in which it is located) provider set up to give

terminally ill patients a coordinated program of inpatient, outpatient, and home care. The Plan

must approve the hospice and treatment plan supervised by a physician.

Hospital: a legally licensed facility that:

is accredited as a hospital under the Hospital Accreditation Program of the Joint

Commission on Accreditation of Hospitals, the American Osteopathic Association

Healthcare Facilities Accreditation Program or is approved by Medicare; or

provides a broad range of 24-hour-a-day medical and surgical services by or under the

direction of a staff of doctors and is engaged primarily in providing either:

o general inpatient medical care and treatment through medical, diagnostic, and

major surgical facilities on its premises or under its control; or

o specialized inpatient medical care and treatment through medical and diagnostic

facilities (including X-ray and laboratory) on its premises and under its control.

The term hospital does not include a facility that primarily is a place for rest, a place for the

aged, or a nursing home.


Illness (or Disease): a pathological condition of the body that presents a group of clinical signs

and symptoms and laboratory findings peculiar to it and that sets the condition apart as an

abnormal entity differing from other normal or pathological body states.

Injury: Bodily harm that is the sole and direct result of an accident.

In-Network Provider: an eligible provider that is contracted by the Plan to provide health care

benefits under the Plan.

Intensive Care Unit: is defined as a separate, clearly designated service area which is

maintained within a Hospital solely for the care and treatment of patients who are critically ill.

This also includes what is referred to as a "coronary care unit" or an "acute care unit."

Leased Employee: as defined in Internal Revenue Code §414(n), as amended.

Legal Guardian; a person recognized by a court of law as having the duty of taking care of the

person and managing the property and rights of a minor child.

Medical Care Facility: means a Hospital, a facility that treats one or more specific ailments or

any type of Skilled Nursing Facility.

Medical Condition: an injury or illness.

Medically or Dentally Necessary: to be medically or dentally necessary, all care must be:

in accordance with standards of good medical or dental practice;

consistent in type, frequency, and duration of treatment with scientifically based

guidelines, as accepted by the Plan;

required for reasons other than the convenience of the health care provider or the

comfort or convenience of the patient;

provided in a cost-efficient manner and type of setting appropriate for the delivery of that

service/supply;

consistent with the diagnosis of the medical or dental condition;

not Experimental or Investigational, as determined by the Plan; and

demonstrated through authoritative medical literature to be safe and effective for treating

or diagnosing the medical or dental condition or illness for which its use is proposed.

The fact that an eligible provider performs or prescribes a procedure or treatment or that it may

be the only treatment for a particular medical condition does not mean that it is medically

necessary as defined here.

The Plan reserves the right to conduct a utilization review to determine whether services are

medically or dentally necessary for the proper treatment of the Participant and may also require

the participant to be independently examined while a claim is pending.


Medicare: The program of health care for the aged established by Title XVIII of the Social

Security Act of 1965, as amended.

Mental Disorder: means any disease or condition, regardless of whether the cause is organic,

that is classified as a Mental Disorder in the current edition of International Classification of

Diseases, published by the U.S. Department of Health and Human Services or is listed in the

current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the

American Psychiatric Association.

Morbid Obesity: means a bodily disorder or disease in which a person’s BMI (Body Mass

Index) is 40 or greater, or 35 or greater with co-morbid conditions including hypertension,

cardiovascular disease, diabetes, pulmonary hypertension of obesity (Pickwickian

Syndrome), or obtrusive sleep apnea.

Network: a group of doctors, hospitals, and other providers contracted by the Plan to provide

health care services for the Plan’s members at agreed-upon rates.

Network Pharmacy: a pharmacy contracted by the Plan to provide prescription drug benefits

under the Plan.

NMHPA: The Newborns’ and Mother’s Health Protection Act of 1996, as amended. Group health

plans and health insurance issuers generally may not, under Federal law, restrict benefits for

any hospital length of stay in connection with childbirth for the mother or newborn child to less

than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section.

However, Federal law generally does not prohibit the mother’s or newborn’s attending provider,

after consulting with the mother, from discharging the mother or her newborn earlier than 48

hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law,

require that a provider obtain authorization from the plan or the insurance issuer for prescribing

a length of stay not in excess of 48 hours (or 96 hours).

Nurse Practitioner: a registered nurse with special training for providing primary health care,

including many tasks customarily performed by a physician.

Out-of-Pocket Maximum: the maximum amount a participant pays for covered medical

expenses (including expenses for covered dependents) in a calendar year. When the out-of-

pocket maximum is reached, the Plan pays 100% of eligible covered expenses for the rest of

the calendar year.

Outpatient Care and/or Services: is treatment including services, supplies and medicines

provided and used at a Hospital under the direction of a Physician to a person not admitted as a

registered bed patient; or services rendered in a Physician's office, laboratory or X-ray facility,

an Ambulatory Surgical Center, or the patient's home.

Participant: an eligible employee or eligible dependent who elects to participate in the Plan by

completing the necessary enrollment forms.


Pharmacy: means a licensed establishment where covered Prescription Drugs are filled and

dispensed by a pharmacist licensed under the laws of the state where he or she practices.

Plan Year: is the 12-month period beginning on either the effective date of the Plan or on the

day following the end of the first Plan Year which is a short Plan Year.

Post-Service Health Claim: a claim for a benefit under the Plan that is a request for payment

under the Plan for covered medical services already received by the Participant. Such a claim

cannot be a pre-service health claim.

PPACA: The Patient Protection and Affordable Care Act of 2010, as amended.

Pregnancy: is childbirth and conditions associated with Pregnancy, including complications.

Pre-Service Health Claim: a claim for a benefit that, under the terms of the Plan, requires a

participant to receive, in whole or in part, prior approval from the Plan as a condition to receive

the benefit. Such a claim cannot be a post-service health claim.

Primary Care Physician: a Family Practice Physician, a Pediatrician, an OB/GYN, or a

General Internist. All other physicians are considered specialists.

Proper Claim: a claim for which a participant has submitted all required information to the Plan

to make a determination.

Prudent Layperson: an individual who is without medical training but possesses an average

knowledge of health and medicine from practical experience and, thus, is able to determine that

the absence of immediate medical attention may result in a serious medical condition for an ill or

injured person.

Qualified Medical Child Support Order (QMCSO) or National Medical Support Notice

(NMSN): any court order that:

provides for child support with respect to the employee's child or directs the employee to

provide coverage under a health benefit plan under a state domestic relations law; or

enforces a law relating to medical child support described in §1908 of the Social Security

Act, with respect to a group health plan. A QMCSO or an NMSN also may be issued

through an administrative process established under state law. A participant must notify

the Plan Administrator if he or she is subject to a QMCSO or an NMSN.

Referral: the process of directing or redirecting (as a medical case or patient) to an appropriate

specialist or agency for definitive treatment.

Retired Employee: is a former Active Employee of the Employer who has retired while

employed by the Employer under formal written plan of the Employer and elects to contribute to

the Plan contribution required from the Retired Employee.

Skilled Nursing Facility: a facility that qualifies under Medicare and is approved by the Plan.


Sub-Acute Facilities: are licensed and accredited to provide professional services to a person

needing extended intensive care services. Services would include, but not limited to, continuous

care for multiple dysfunctions involving multiple body systems, constant monitoring with 10-12

hours of critical care, complete medical record for each patient, complex care of

ventilator/dialysis/extensive wound care, Utilization review, 24-hr in-house monitoring of

respiratory therapy, registered dietician, licensed pharmacist (24-hr coverage) and specialized

wound care team.

Substance Abuse: is regular excessive compulsive drinking of alcohol and/or physical habitual

dependence on drugs. This does not include dependence on tobacco and ordinary

caffeine-containing drinks.

Temporomandibular Joint Dysfunction (TMJ): Pain, swelling, clicking, grinding, popping,

dislocation, locking, malposition, bite discrepancies or other pathological conditions which

create a loss or decrease of function in or around one or both of the jaw joints.

Totally Disabled: A person who is determined as disabled for Social Security purposes.

Uniformed Services Employment and Reemployment Rights Act of 1994 (“USERRA”): a

Federal law covering the rights of participants who have a qualified uniformed services leave.

Urgent Pre-Service Health Claim: a claim for medical treatment which, if the regular time

periods observed for claims were adhered to:

could seriously jeopardize the life or health of the claimant or the ability of the claimant to

regain maximum function; or

in the opinion of a physician with knowledge of the claimant’s medical condition, would

subject the claimant to severe pain that cannot be adequately managed.

Any claim that a physician with knowledge of the claimant’s medical condition determines to be

a “claim involving urgent care” will be deemed to be an urgent pre-service health claim.

Otherwise, whether a claim is an urgent pre-service health claim or not will be determined by an

individual acting on behalf of the Plan, and applying the judgment of a prudent layperson.

Usual and Customary: if you use out-of-network providers, covered medical expenses are

subject to certain limits under the Plan, and you are responsible for paying any charges above

this limit. The maximum benefit payable is based on the amount determined by the Plan to be

the prevailing charge for a covered service or supply. Determination of the prevailing charge is

based on the:

complexity of the service and level of specialty of the provider;

range of services provided; and

the geographic area where the provider is located and other geographic areas with

similar medical cost experience.

The Plan Administrator has the discretionary authority to decide whether a charge is Usual and

Reasonable.


WHCRA: The Women’s Health and Cancer Rights Act of 1998, as amended.


SECTION II: PLAN OVERVIEW

Your Eligibility

You are eligible for benefits if you are:

An Active Employee who is:

o normally scheduled to work a minimum of 30 hours per week;

o on the regular payroll of the Plan Sponsor; and

o in a class of employees eligible for coverage; or

A Retired Employee, as defined below, of the Employer.

The following individuals are not eligible for benefits: seasonal employees, leased employees,

employees of a temporary or staffing firm, payroll agency, or leasing organization, contract

employees, independent contractors, any person who is on active duty in any military service of

any country for longer than two (2) weeks, unless coverage may be extended pursuant to

USERRA, and other individuals who are not on the Plan Sponsor payroll, as determined by the

Plan Sponsor, without regard to any court or agency decision determining common-law

employment status.

Eligible Dependents

You may enroll your eligible dependents on your coverage. Your eligible dependents include:

your legal spouse who is a resident of the same country in which the Employee resides.

The term “spouse” shall include any individuals who are lawfully married. The Plan

Administrator may require documentation proving a legal marital relationship;

a dependent of a Retiree, who continues to meet all other eligibility requirements, and

who is eligible to continue coverage under the Plan as defined below;

your child under age 26 regardless of financial dependency, residency with you, marital

status, or student status; and

your unmarried child of any age who is not capable of self-support due to a physical or

mental disability that occurred before age 26, whose disability is continuous, and who is

principally supported by you. The Plan Administrator may require, at reasonable

intervals during the two years following the Dependent's reaching the limiting age,

subsequent proof of the child's Total Disability and dependency.

After such two-year period, the Plan Administrator may require subsequent proof not

more than once each year. The Plan Administrator reserves the right to have such

Dependent examined by a Physician of the Plan Administrator's choice, at the Plan's

expense, to determine the existence of such incapacity.

“Principally supported by you” means that the child is dependent on you for more than one-half

of his or her support, as defined by §152 of the Internal Revenue Code.


For purposes of the Plan, your child includes:

your biological child;

a child for whom the Covered Employee and/or Spouse have been named Legal

Guardian;

your legally adopted child (including any child under age 18 placed in the home during a

probationary period in anticipation of the adoption where there is a legal obligation for

support);

a step child as long as you are married to the child’s natural parent; or

an eligible child for whom you are required to provide coverage under the terms of a

QMCSO or a NMSN.

An eligible dependent does not include:

a person enrolled as an employee under the Plan;

any person who is in active military services;

a foster child;

a legally separated Spouse;

a former Spouse;

a domestic partner; and

a domestic partner’s child(ren)

In addition, an eligible dependent who lives outside the U.S. cannot be covered as your

dependent, unless the dependent has established his or her primary residence with you.

It is your responsibility to notify the Plan Sponsor if your dependent becomes ineligible for

coverage.

Working Spouse Rule

The purpose of the Working Spouse Rule is to share the costs of the medical expenses with

other plans or insurance carriers when the Spouse of an Employee is eligible for medical

coverage where the spouse is employed. (Medicare does not count as an employer-sponsored

plan for the purpose of this rule).

If a Spouse of an eligible Employee is employed with a company which offers group

medical insurance coverage and that Spouse is eligible for that plan, that Spouse will not

be eligible for this Plan.

If the Spouse is employed with a company that does not offer group medical coverage or

is ineligible to be enrolled, the Spouse may be enrolled in this Plan at the current

applicable rate. (A statement from the Spouse’s employer that verifies they have no

coverage available with that employer will be required).


Proof of Dependent Eligibility

The Plan Sponsor reserves the right to verify that your dependent is eligible or continues to be

eligible for coverage under the Plan. If you are asked to verify a dependent’s eligibility for

coverage, you will receive a notice describing the documents that you need to submit. To ensure

that coverage for an eligible dependent continues without interruption, you must submit the

required proof within the designated time period. If you fail to do so, coverage for your

dependent may be canceled retroactively.

Eligible Retirees

A retired Employee will be eligible to continue coverage upon retirement from employment with

City of Columbus if the following has been met:

Retired Public Safety Employees

A Public Safety Employee who, on or after June 30, 1989, retires or receives disability

benefits (under Ind. Code § 36-8-6, 7, 7.5, 8, and 10) may elect coverage for himself, his or

her spouse, and Dependents if the following criteria are met:

he or she is not eligible for Medicare on the date that he or she retires or becomes

eligible for disability payments pursuant to the statutory provisions referenced above;

files a written request to the City of Columbus within ninety (90) days after the

employee's retirement date or the date he or she begins receiving disability payments;

and

employee agrees to make timely payment for premiums in an amount determined by

the Employer (which cannot exceed the total amount paid by the Employer and an

active Employee for equivalent coverage).

The surviving spouse and Dependents of a Public Safety Employee who dies while in active service

or after retirement may continue coverage for himself or herself and his or her Dependents. In

order to continue coverage, the spouse or Dependent must file a written request for

coverage on a form satisfactory to the Employer within ninety (90) days after the employee's

death. He or she must also make timely payment of an amount determined by the Employer but

not more than the total amount paid by the Employer and an active Employee for equivalent

coverage.

Retired Employees (non-Public Safety Employees)

A retired Employee (other than Public Safety Employees) who retires on or after June 30,

1986 may elect coverage for himself, his or her spouse, and Dependents if the following

criteria are met:

completed twenty (20) years of creditable employment with a public employer, ten (10)

years of which must have been completed immediately prior to his or her retirement

date;

completed fifteen (15) years of participation in the Employer's retirement plan on or

before his or her retirement date;

reached age 55;


not eligible for Medicare on his or her retirement date;

filed a written request to City of Columbus within ninety (90) days after the employee's

retirement date or the date he begins receiving disability payments; and

employee agrees to make timely payment of an amount determined by the Employer but

not more than the total amount paid by the Employer and an active Employee for

equivalent coverage.

Coverage is available to all retired Employees who meet the defined criteria listed above and to

all eligible Dependents of the retired Employee. All eligible retirees will be required to elect

coverage in writing each year to continue their coverage. The Retired Employee is required to

pay the amount as set by the Plan Administrator.

When Coverage Begins

Look-back Measurement Method for Determining Full-time Employee Status

City of Columbus uses the look-back measurement method to determine who is a full-time

employee for purposes of the Plan’s health care benefits. The look-back measurement method

is based on Internal Revenue Service (IRS) final regulations.

The look-back measurement method applies to:

All employees

The look-back measurement method involves three different periods:

Measurement period

Stability period

Administrative period

The measurement period is a period for counting your hours of service. Different measurement

periods apply to ongoing employees, new employees who are variable hour, seasonal or part-

time, and new non-seasonal employees who are expected to work full time.

If you are an ongoing employee, this measurement period is called the “standard measurement

period.” Your hours of service during the standard measurement period will determine your

eligibility for the Plan’s health care benefits for the stability period that follows the standard

measurement period and any administrative period.

If you are a new employee who is variable hour, seasonal or part-time, this measurement period

is called the “initial measurement period.” Your hours of service during the initial measurement

period will determine your eligibility for the Plan’s health care benefits for the stability period that

follows the initial measurement period and any administrative period.

If you are a new non-seasonal employee who is expected to work full time, City of Columbus will

determine your status as a full-time employee who is eligible for the Plan’s health care benefits

based on your hours of service for each calendar month. Once you have been employed for a

certain length of time, the measurement rules for ongoing employees will apply to you.


The stability period is a period that follows a measurement period. Your hours of service during

the measurement period will determine whether you are considered a full-time employee who is

eligible for health care benefits during the stability period. As a general rule, your status as a full-

time employee or a non-full-time employee is “locked in” for the stability period, regardless of

how many hours you work during the stability period, as long as you remain an employee of City

of Columbus. There are exceptions to this general rule for employees who experience certain

changes in employment status.

An administrative period is a short period between the measurement period and the stability

period when City of Columbus performs administrative tasks, such as determining eligibility for

coverage and facilitating Plan enrollment. The administrative period may last up to 90 days.

However, the initial measurement period for new employees and the administrative period

combined cannot extend beyond the last day of the first calendar month beginning on or after

the one-year anniversary of the employee’s start date (totaling, at most, 13 months and a

fraction of a month).

Special rules may apply in certain circumstances, such as when employees are rehired by City

of Columbus or return from unpaid leave.

The rules for the look-back measurement method are very complex. Keep in mind that this

information is a summary of how the rules work. More complex rules may apply to your

situation.

City of Columbus intends to follow applicable IRS guidance when administering the look-back

measurement method. If you have any questions about this measurement method and how it

applies to you, please contact the Plan Administrator.

For You

Your health care coverage begins the first day of employment after you meet all eligibility

requirements.

For Your Dependents

If you enroll your eligible dependents within 31 days of your initial eligibility, their coverage

begins at the same time as yours.

If both parents are Employees with City of Columbus, their children will be covered as a

Dependent of one of the parents, but not both. Coverage for newly eligible Dependents will

begin on the date they become a Dependent as long as you enroll them within 31 days of the

date on which they became eligible.

If you are covered under this Plan, and change status from Employee to Dependent, or

Dependent to Employee, and both of you have been covered continuously under this Plan

before, during and after the change in status, credit will be given for Deductible, Copay and/ or

Coinsurance amounts.


If two Employees (Spouses) are covered under the Plan and the Employee who is covering the

Dependent children terminates coverage, the Dependent coverage may be continued by the

other covered Employee with no Waiting Period, as long as coverage has been continuous.

Credit will be given for Deductible, Copay and/ or Coinsurance amounts.

If you acquire a new Dependent, such as a through marriage, dependent birth or an adoption or

placement for adoption, coverage will take effect on the date of the marriage, birth, the date of

the adoption, or placement for adoption, as long as you enroll the dependent within 31 days of

the date on which they became eligible.

A newborn child born while you are enrolled for medical coverage will automatically be covered

on your Plan from birth for a period of thirty-one (31) days. Coverage will continue for the

newborn as long as you enroll them within thirty-one (31) days of the date on which they

became eligible. If you wait longer than 31 days, you may not be able to enroll the newborn until

the next annual enrollment period. Charges for nursery and physician care for the newborn will

be applied toward the plan of the covered newborn. A separate deductible and coinsurance will

apply to charges incurred by the newborn child.

Your Cost for Coverage

Both the Plan Sponsor and you share in the cost of your health care benefits. Each year, the

Plan Sponsor will evaluate all costs and may adjust the cost of coverage during the next annual

enrollment. Your enrollment materials will show the coverage categories available to you.

You pay your portion of this cost through pre-tax payroll deductions taken from your pay each

pay period. Your actual cost is determined by the coverage you select and the number of

dependents you cover. You must elect coverage for yourself in order to cover your eligible

dependents.

Enrolling for Coverage

New Hire Enrollment

As a newly eligible employee, you will receive enrollment information when you first become

eligible for benefits. To enroll in medical and prescription drug coverage, you will need to make

your coverage elections by the deadline shown in your enrollment materials. When you enroll in

the Plan, you authorize the Plan Sponsor to deduct any required premiums from your pay.

The elections you make will remain in effect until the next January 1, unless you have a

qualifying change in status. After your initial enrollment, you will enroll during the designated

open enrollment period. If you do not enroll for coverage when initially eligible, you will only be

eligible for the default coverages designated by the Plan Administrator, if applicable, as shown

in your enrollment materials.

You will automatically receive identification (ID) cards when your enrollment is processed.


Late Entrant

Your enrollment will be considered timely if your completed enrollment form is received within 31

days after you become eligible for coverage. You will be considered a “late entrant” if:

You elect coverage more than 31 days after you first become eligible; or

You again elect coverage after cancelling.

Unless the Special Enrollment Rights apply, if you are a late entrant, you will be required to wait

until the next open enrollment period.

Open Enrollment

Every 4th Quarter (time to be announced), during the open enrollment period, you will be given

the opportunity to make your elections for the upcoming year. Your open enrollment materials

will provide the options available to you and your share of the premium cost, as well as any

default coverage, if applicable, you will be deemed to have elected if you do not make an

election by the specified deadline. The elections you make will take effect on January 1 and stay

in effect through December 31, unless you have a qualifying change in status.

Every 4th Quarter (time to be announced) during the open enrollment period, covered

Employees and their covered Dependents will be able to change some of their benefit decisions

based on which benefits and coverages are right for them.

During the designated open enrollment period, Employees and their Dependents who are Late

Enrollees will be able to enroll in the Plan.

Benefit choices made during the open enrollment period will become effective on January 1 of

each year and remain in effect unless there is a Special Enrollment event or a change in family

status during the year (birth, death, marriage, divorce or adoption) or loss of coverage due to

loss of a Spouse's employment. To the extent previously satisfied, coverage Waiting Periods will

be considered satisfied when changing from one benefit option under the Plan to another

benefit option under the Plan.

Benefit choices for Late Enrollees made during the open enrollment period will become effective

January 1.

Plan Participants will receive detailed information regarding open enrollment from their

Employer.

Effect of Section 125 Tax Regulations on this Plan

It is intended that this Plan meets the requirements of Internal Revenue Code (“IRC”) §125 and

the regulations thereunder and that the qualified benefits which you may elect are eligible for

exclusion from income. The Plan is designed and administered in accordance with those

regulations. This enables you to pay your share of the cost for coverage on a pre-tax basis.

Neither the Plan Sponsor nor any fiduciary under the Plan will in any way be liable for any taxes

or other liability incurred by you by virtue of your participation in the Plan.


Because of this favorable tax-treatment, there are certain restrictions on when you can make

changes to your elections. Generally, your elections stay in effect for the Plan Year and you can

make changes only during each open enrollment. However, at any time throughout the year, you

can make changes to your coverage within 31 days of the following:

The date you have a qualifying change in status;

The date you meet the Special Enrollment Rights criteria described.

Qualifying Change in Status

If you experience a change in certain family or employment circumstances that results in you or

a covered dependent gaining or losing eligibility under a health plan, you can change your

coverage to fit your new situation without waiting for the next open enrollment period.

As defined by the Internal Revenue Service (IRS), status changes applicable to health care

coverage include:

marital status changes (e.g., marriage, legal separation, annulment, or divorce);

changes in the number of dependents (e.g., increase through birth or adoption, or

decrease through death);

changes in residence that affect eligibility (i.e., moving out coverage area for a managed

care option);

changes in employment status of employee or dependent that affects eligibility for Plan

(e.g., change from full-time to part-time, commencement or return from unpaid leave, or

termination);

changes in hours of service that affect eligibility under the Plan;

cessation of coverage in order to purchase coverage through the Marketplace

established under the PPACA;

a dependent ceases to qualify as such under the Plan (i.e., becomes ineligible or regains

eligibility); and

any of the HIPAA special enrollment events (please see section titled “Special

Enrollment Rights”).

In certain limited circumstances, an employee may make changes to his or her coverage if the

following Change in Status events require him or her to do so:

Judgment, decree or order (i.e., qualified medical child support order);

Entitlement to Medicare or Medicaid, or a loss of such entitlement (please note that this

does not include state CHIP, Veteran’s Affairs, or TRICARE benefits);

Significant mid-year Plan changes (e.g., significant changes in the cost of coverage or

significant curtailment of coverage); and

Certain required circumstances under Family and Medical Leave Act of 1993 (“FMLA”)

when applicable to your employer (please see below section titled “Continuation during

Family and Medical Leave”)


If you believe that you have experienced a Change in Status, you should report that change and

fill out any necessary forms as soon as possible, but no later than 31 days, after the event

occurs.

Special Enrollment Rights

If you decline enrollment for yourself or your dependents because you have other health

coverage, you may be able to enroll yourself and your dependents in this Plan, if you or your

dependents lose eligibility for that other coverage (or if the employer stopped contributing

towards your or your dependents' other coverage). However, you must request enrollment

within 31 days after your or your dependents' other coverage ends (or after the employer stops

contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement

for adoption, you may be able to enroll yourself and your dependents. However, you must

request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

You or an affected eligible dependent may also enroll in coverage if eligibility for coverage is lost

under Medicaid or the Children’s Health Insurance Program (CHIP), or if you become eligible for

premium assistance under Medicaid or CHIP. You must enroll under this Plan within 60 days of

the date you lose coverage or become eligible for premium assistance.

This “special enrollment right” exists even if you previously declined coverage under the Plan.

You will need to provide documentation of the change. Contact the Plan Administrator to

determine what information you will need to provide.

When Coverage Ends

Your coverage under this Plan ends on the last day of the calendar month in which you cease to

be in one of the Eligible Classes. This includes death or termination of Active Employment, or

the date your Eligible Class is eliminated, unless benefits are extended through COBRA;

Coverage for your covered dependents ends when your coverage ends or, if earlier, on the day

your dependent is no longer eligible for coverage. However, for a dependent child who reaches

the limiting age, coverage will end on the last day of the calendar month of their birthday.

Coverage will also end for you and your covered dependents as of the date the Plan Sponsor

terminates this Plan or, if earlier, the date you request termination of coverage for you and your

covered dependents.

If your coverage under the Plan ends for reasons other than the Plan Sponsor’s termination of

all coverage under the Plan, you and/or your eligible dependents may be eligible to elect to

continue coverage under COBRA.


Reinstatement of Coverage

If you terminate employment and are subsequently rehired, you will be treated as a new

employee and will need to satisfy all eligibility requirements in order to be covered under the

Plan unless the following scenarios apply to your situation.

A rehired employee would retain previous eligibility and not be treated as a new employee if:

an employee has more than 13 consecutive weeks of experience in his/her previous

period of employment, an employee has a break of service of less than 13 weeks; or

an employee has less than 13 consecutive weeks of experience in a previous period of

employment, an employee has a break of service that does not exceed 4 weeks or a

break of service that does not exceed his/her previous period of employment.

For a Retired Public Safety Employee, your coverage ends on the earliest of the following:

the date the person (Retired Public Safety Employee, surviving spouse, or Dependent)

becomes eligible for Medicare (i.e., turns 65, etc.);

the date the Employer terminates health coverage for active Public Safety Employees;

or

the first day of the month for which a person fails to make timely payment of premiums;

AND in addition, in the case of a surviving spouse:

the date of the spouse's remarriage;

the date health benefits become available through surviving spouse's own employment;

or

the date health insurance become available through a new employer;

AND in addition, in the case of a Dependent:

the date the Dependent fails to meet the definition of a Dependent; or

the date health insurance become available through a new employer.

For a Retired Employees (non- Public Safety Employees), your coverage ends on the earliest of the following:

the date the person (Retired Employee, surviving spouse, or Dependent) becomes eligible

for Medicare (i.e., turns 65, etc.);

the date the Employer terminates health coverage for active Employees; or

the first day of the month for which a person fails to make timely payment of premiums;

AND in addition, in the case of a surviving spouse:

the date of the spouse's remarriage; or

two (2) years after the death of the Employee

AND in addition, in the case of a Dependent, the date the Dependent fails to meet the

definition of a Dependent.


Cancellation of Coverage

If you fail to pay any required premium for coverage under the Plan, coverage for you and your

covered dependents will be canceled and no claims incurred after the effective date of

cancellation will be paid.

Rescission of Coverage

Coverage under the Plan may be rescinded (canceled retroactively) if you or a covered

dependent perform an act, practice, or omission that constitutes fraud, or you make an

intentional misrepresentation of material fact as prohibited by the terms of the Plan.

Coverage will be canceled prospectively for errors in coverage or if no fraud or intentional

misrepresentation was made by you or your covered dependent. You will receive 30 days

advance written notice of any cancellation of coverage to be made on a prospective basis.

The Plan reserves the right to recover from you and/or your covered dependents any benefits

paid as a result of the wrongful activities that are in excess of the premiums paid. In the event

the Plan terminates or rescinds coverage for gross misconduct on your behalf, continuation

coverage under COBRA may be denied to you and your covered dependents.

Coverage While Not at Work

In certain situations, health care coverage may continue for you and your dependents when you

are not at work, so long as you continue to pay your share of the cost. If you continue to be paid

while you are absent from work, any premium payments will continue to be deducted from your

pay on a pre-tax basis. If you are not receiving your pay during an absence, you will need to

make arrangements for payment of any required premiums. You should discuss with your

supervisor what options are available for paying your share of costs while you are absent from

work.

If You Are Disabled or FMLA Approved Leave

If you become disabled or take an approved FMLA Leave of Absence, your coverage will

terminate at the end of the 13th week after benefits begin unless additional leave is approved as

provided above and required by applicable laws and regulations (i.e., the Americans with

Disabilities Act (“ADA”).

If You Are Temporarily Laid Off

If you are laid off for a temporary period of time, your coverage will end on the day in which you

cease to be in one of the Eligible Classes.

Leave of Absence

If you take a leave of absence, your coverage will end on the last day of the calendar month in

which you cease to be in one the Eligible Classes, unless benefits are extended through

COBRA.


While continued, coverage will be the same as it was on the last day worked as an Active

Employee. However, if benefits reduce for others in the class, they will also reduce for you.

Continuation during Family and Medical Leave

This Plan shall at all times comply with the FMLA as promulgated in regulations issued by the

Department of Labor to the extent it does not otherwise conflict with other relevant laws and

regulations (i.e., ADA).

To the extent the FMLA applies to the Employer, group health benefits may be maintained

during certain leaves of absence at the level and under the conditions that would have been

present as if employment had not been interrupted. Employee eligibility requirements, the

obligations of the Employer and Employee concerning conditions of leave, and notification and

reporting requirements are specified in the FMLA. Any Plan provisions which conflict with the

FMLA are superseded by the FMLA to the extent such provisions conflict with the FMLA. An

Employee with questions concerning any rights and/or obligations should contact his Employer.

If You Take a Military Leave of Absence

If you are absent from work due to an approved military leave, health care coverage may

continue for up to 24 months under both USERRA and COBRA, which run concurrently, starting

on the date your military service begins.

If You Are Permanently Laid Off

If you are permanently laid off (separated from service), your coverage under this Plan ends on

the last day of the calendar month in which you cease to be an Active Employee.


SECTION III: YOUR MEDICAL BENEFITS

Your medical benefits are delivered through a network of participating doctors, hospitals,

laboratories, home health care agencies, and other health care providers, who have agreed to

provide services at a discounted cost.

All benefits described in this SPD are subject to the exclusions and limitations described more

fully herein including, but not limited to, the Plan Administrator's determination that: care and

treatment is Medically Necessary; that charges are Usual and Customary; that services,

supplies and care are not Experimental and/or Investigational. The meanings of these

capitalized terms are in the Defined Terms section of this document.

This Plan contains a Participating Provider Organization (PPO) which is a group contracted

providers that provide services at negotiated rates. Please refer to your identification card for

information about your PPO network(s).

PPO name: Inspire Network Address: PO Box 1787 Columbus, IN 47202 Telephone: (800) 443-2980 Website: www.siho.org PPO name: SIHO Network Address: PO Box 1787 Columbus, IN 47202 Telephone: (800) 443-2980 Website: www.siho.org

Out-of-Area PPO name: PHCS Healthy Directions

Address: 1100 Winter St.

Waltham, MA 02451

Telephone: 1-888-779-7427

Website: www.multiplan.com

Therefore, when a Plan Participant uses a Network Provider, that Plan Participant will receive a

higher payment from the Plan than when a Non-Network Provider is used. It is the Plan

Participant's choice as to which Provider to use.

In some cases, Plan Participants (Employees and Dependents) receive health care services or

supplies from non-network facilities and providers. In order to assist the Plan Sponsor in

reducing the cost of health care in these circumstances, the Plan may access additional network

vendors through contractual arrangements established by the Claims Administrator and its

affiliated entities. In the event a particular facility or provider is not contracted with any other

specific network listed in this SPD as of the applicable date of the particular health care service

or supply, the Plan Sponsor reserves the right to establish another network for the purpose of

potentially reducing the cost of services and/or preventing the provider from balance billing the

http://www.siho.org/http://www.siho.org/http://www.multiplan.com/


Plan Participants. In the below circumstances, the In-Network payment will be made for certain

Non-Network services; otherwise, the payment will apply to the Out-of-Network benefit level.

Under the following circumstances, the higher In-Network payment will be made for certain

Non-Network services:

If a Plan Participant has no choice of Network Providers in the specialty that the Plan Participant

is seeking within the PPO service area, services will apply to the Tier 1 Inspire benefit level.

If a Plan Participant has an Emergency Medical Condition requiring immediate care benefits will

apply to the Tier 1 Inspire benefit level.

If a Plan Participant receives Physician or anesthesia services from a Non-Network Radiologist,

ER Physician, Pathologist or Anesthesiologist at an In-Network facility, the benefit will apply to

the same Tier benefit level as the facility where services were rendered.

If a Plan Participant receives Physician services from a Radiologist, ER Physician, Pathologist or

Anesthesiologist that is in the Tier 2 or Tier 3 Network but services are provided at a higher Tier

Network facility, the benefit will apply to the same Tier benefit level as the facility where services

were rendered.

If a Plan Participant has lab work taken by a network Physician, but the Physician sends it to a

Non-Network facility for evaluation, services will apply to the same Tier benefit level as the

ordering Physician.

If a Plan Participant utilizes a PHCS Healthy Directions Provider while traveling or living outside

the PPO service area, services will apply to the Tier 1, Inspire benefit level.

If a Plan Participant resides outside the PPO service area, such as a full time student, and

receives services at a Non-Network provider, services will apply to the Tier 1, Inspire benefit

level.

The Plan does not require you to select a primary care physician to coordinate your care and

you do not have to obtain a referral to see a specialist.

A network of providers gives you the flexibility to choose providers inside or outside the network

each time you need care. In most cases, the Plan covers the same medical services whether

you receive care in- or out-of-network. Refer to the Summary of Medical Benefits for more

information.

To select a Primary Care Physician or “PCP,” or to obtain a listing of current providers (at no

cost to you) or confirm whether a provider participates in the network, contact the Claims

Administrator for the network by visiting www.siho.org.

If you use in-network providers, the Plan pays a higher percentage of covered expenses

(after you meet any applicable deductible). Generally, you will not be required to file a claim

form when you receive in-network benefits but in some cases, the provider or Claims

Administrator may require you to do so.

http://www.siho.org/

City of Columbus Employee Benefit Plan

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